Publications by authors named "Matthew J McGirt"

288 Publications

Early postoperative physical activity and function: a descriptive case series study of 53 patients after lumbar spine surgery.

BMC Musculoskelet Disord 2020 Nov 27;21(1):783. Epub 2020 Nov 27.

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1215 21st Avenue South, Medical Center East - South Tower, Suite 4200, Nashville, TN, 37232, USA.

Background: The purpose of this prospective case series study was to compare changes in early postoperative physical activity and physical function between 6 weeks and 3 and 6 months after lumbar spine surgery.

Methods: Fifty-three patients (mean [95% confidence interval; CI] age = 59.2 [56.2, 62.3] years, 64% female) who underwent spine surgery for a degenerative lumbar condition were assessed at 6 weeks and 3- and 6-months after surgery. The outcomes were objectively-measured physical activity (accelerometry) and patient-reported and objective physical function. Physical activity was assessed using mean steps/day and time spent in moderate to vigorous physical activity (MVPA) over a week. Physical function measures included Oswestry Disability Index (ODI), 12-item Short Form Health Survey (SF-12), Timed Up and Go (TUG), and 10-Meter Walk (10 MW). We compared changes over time in physical activity and function using generalized estimating equations with robust estimator and first-order autoregressive covariance structure. Proportion of patients who engaged in meaningful physical activity (e.g., walked at least 4400 and 6000 steps/day or engaged in at least 150 min/week in MVPA) and achieved clinically meaningful changes in physical function were compared at 3 and 6 months.

Results: After surgery, 72% of patients initiated physical therapy (mean [95%CI] sessions =8.5 [6.6, 10.4]) between 6 weeks and 3 months. Compared to 6 weeks post-surgery, no change in steps/day or time in MVPA/week was observed at 3 or 6 months. From 21 to 23% and 9 to 11% of participants walked at least 4400 and 6000 steps/day at 3 and 6 months, respectively, while none of the participants spent at least 150 min/week in MVPA at these same time points. Significant improvements were observed on ODI, SF-12, TUG and 10 MW (p <  0.05), with over 43 to 68% and 62 to 87% achieving clinically meaningful improvements on these measures at 3 and 6 months, respectively.

Conclusion: Limited improvement was observed in objectively-measured physical activity from 6 weeks to 6 months after spine surgery, despite moderate to large function gains. Early postoperative physical therapy interventions targeting physical activity may be needed.
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http://dx.doi.org/10.1186/s12891-020-03816-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7697379PMC
November 2020

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy.

Spine (Phila Pa 1976) 2020 Nov;45(22):1541-1552

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee.

Study Design: Retrospective analysis of prospectively collected registry data.

Objective: To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

Summary Of Background Data: Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

Methods: This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

Results: Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

Conclusions: These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003610DOI Listing
November 2020

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses.

Phys Ther 2020 09;100(10):1793-1804

Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Medical Center East - South Tower, Suite 4200, Nashville, TN 37232 (USA); Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center.

Objective: Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery.

Methods: In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months.

Results: Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]).

Conclusions: This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism.

Impact: Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.
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http://dx.doi.org/10.1093/ptj/pzaa112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530577PMC
September 2020

Quality Outcomes Database Spine Care Project 2012-2020: milestones achieved in a collaborative North American outcomes registry to advance value-based spine care and evolution to the American Spine Registry.

Neurosurg Focus 2020 05;48(5):E2

4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).
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http://dx.doi.org/10.3171/2020.2.FOCUS207DOI Listing
May 2020

Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases.

Neurosurgery 2020 03;86(3):E310-E315

Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina.

Background: In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety.

Objective: To analyze 2000 ASC-ACDF cases, describe patient selection and perioperative protocol, and report associated safety profile.

Methods: A total of 2000 patients who underwent 1 to 3 level ACDF in a single ASC from 2006 to 2018 were included in this retrospective analysis. Patients were observed in a 4-h postanesthesia care unit (PACU) with a multimodal pain management regiment. Data were collected on patient demographics, comorbidities, operative details, and 30- and 90-d morbidity.

Results: Of the 2000 patients, 10 (0.5%) required transfer to an inpatient setting within the 4-h observation. Reasons for transfer included hematoma (2), pain control (2), cerebrospinal fluid leak (1), and medical complications (5). Six patients (0.3%) underwent reoperation within 30 d. All-cause 30-d readmission was 1.9%.

Conclusion: An analysis of 2000 ACDF patients in an ASC setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in a 4-h PACU. In an effort to decrease healthcare costs, surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here.
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http://dx.doi.org/10.1093/neuros/nyz514DOI Listing
March 2020

Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy.

Neurosurgery 2020 06;86(6):763-768

Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background: Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored.

Objective: To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM.

Methods: This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest.

Results: A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in.

Conclusion: Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.
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http://dx.doi.org/10.1093/neuros/nyz325DOI Listing
June 2020

Does Neck Disability Index Correlate With 12-Month Satisfaction After Elective Surgery for Cervical Radiculopathy? Results From a National Spine Registry.

Neurosurgery 2020 05;86(5):736-741

Department of Orthopaedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.

Background: Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients' quality of life.

Objective: To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR.

Methods: The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients' demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction.

Results: The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score.

Conclusion: Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.
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http://dx.doi.org/10.1093/neuros/nyz231DOI Listing
May 2020

Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure.

Clinicoecon Outcomes Res 2019 28;11:191-197. Epub 2019 Feb 28.

Sierra Neuroscience Institute, Los Angeles, CA, USA,

Purpose: Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy.

Patients And Methods: This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period.

Results: Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD.

Conclusion: Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.
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http://dx.doi.org/10.2147/CEOR.S193603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400234PMC
February 2019

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy.

Spine (Phila Pa 1976) 2019 Jun;44(11):801-808

Department of Neurosurgery, University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic and Spine Institute, Memphis, TN.

Study Design: This study retrospectively analyzes prospectively collected data.

Objective: Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM).

Summary Of Background Data: DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored.

Methods: The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest.

Results: We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001).

Conclusion: Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002946DOI Listing
June 2019

A predictive model and nomogram for predicting return to work at 3 months after cervical spine surgery: an analysis from the Quality Outcomes Database.

Neurosurg Focus 2018 11;45(5):E9

3Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina.

OBJECTIVEBack pain and neck pain are two of the most common causes of work loss due to disability, which poses an economic burden on society. Due to recent changes in healthcare policies, patient-centered outcomes including return to work have been increasingly prioritized by physicians and hospitals to optimize healthcare delivery. In this study, the authors used a national spine registry to identify clinical factors associated with return to work at 3 months among patients undergoing a cervical spine surgery.METHODSThe authors queried the Quality Outcomes Database registry for information collected from April 2013 through March 2017 for preoperatively employed patients undergoing cervical spine surgery for degenerative spine disease. Covariates included demographic, clinical, and operative variables, and baseline patient-reported outcomes. Multiple imputations were used for missing values and multivariable logistic regression analysis was used to identify factors associated with higher odds of returning to work. Bootstrap resampling (200 iterations) was used to assess the validity of the model. A nomogram was constructed using the results of the multivariable model.RESULTSA total of 4689 patients were analyzed, of whom 82.2% (n = 3854) returned to work at 3 months postoperatively. Among previously employed and working patients, 89.3% (n = 3443) returned to work compared to 52.3% (n = 411) among those who were employed but not working (e.g., were on a leave) at the time of surgery (p < 0.001). On multivariable logistic regression the authors found that patients who were less likely to return to work were older (age > 56-65 years: OR 0.69, 95% CI 0.57-0.85, p < 0.001; age > 65 years: OR 0.65, 95% CI 0.43-0.97, p = 0.02); were employed but not working (OR 0.24, 95% CI 0.20-0.29, p < 0.001); were employed part time (OR 0.56, 95% CI 0.42-0.76, p < 0.001); had a heavy-intensity (OR 0.42, 95% CI 0.32-0.54, p < 0.001) or medium-intensity (OR 0.59, 95% CI 0.46-0.76, p < 0.001) occupation compared to a sedentary occupation type; had workers' compensation (OR 0.38, 95% CI 0.28-0.53, p < 0.001); had a higher Neck Disability Index score at baseline (OR 0.60, 95% CI 0.51-0.70, p = 0.017); were more likely to present with myelopathy (OR 0.52, 95% CI 0.42-0.63, p < 0.001); and had more levels fused (3-5 levels: OR 0.46, 95% CI 0.35-0.61, p < 0.001). Using the multivariable analysis, the authors then constructed a nomogram to predict return to work, which was found to have an area under the curve of 0.812 and good validity.CONCLUSIONSReturn to work is a crucial outcome that is being increasingly prioritized for employed patients undergoing spine surgery. The results from this study could help surgeons identify at-risk patients so that preoperative expectations could be discussed more comprehensively.
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http://dx.doi.org/10.3171/2018.8.FOCUS18326DOI Listing
November 2018

Effect of Depression on Patient-Reported Outcomes Following Cervical Epidural Steroid Injection for Degenerative Spine Disease.

Pain Med 2018 12;19(12):2371-2376

Departments of Orthopaedic Surgery.

Objective: To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs).

Design: Retrospective review of a prospectively collected database.

Setting: Single institution tertiary care center.

Subjects: Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included.

Methods: Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success.

Results: Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P < 0.002 AP, P < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P < 0.01). There was no difference in outcomes between groups on the EQ-5D.

Conclusions: Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months.
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http://dx.doi.org/10.1093/pm/pny196DOI Listing
December 2018

Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease.

Neurosurgery 2019 05;84(5):1043-1049

Departments of Orthopedic and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d.

Objective: To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery.

Methods: A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost.

Results: The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64.

Conclusion: Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.
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http://dx.doi.org/10.1093/neuros/nyy264DOI Listing
May 2019

Development and validation of a predictive model for 90-day readmission following elective spine surgery.

J Neurosurg Spine 2018 Sep 15;29(3):327-331. Epub 2018 Jun 15.

3Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and.

OBJECTIVE Hospital readmissions lead to a significant increase in the total cost of care in patients undergoing elective spine surgery. Understanding factors associated with an increased risk of postoperative readmission could facilitate a reduction in such occurrences. The aims of this study were to develop and validate a predictive model for 90-day hospital readmission following elective spine surgery. METHODS All patients undergoing elective spine surgery for degenerative disease were enrolled in a prospective longitudinal registry. All 90-day readmissions were prospectively recorded. For predictive modeling, all covariates were selected by choosing those variables that were significantly associated with readmission and by incorporating other relevant variables based on clinical intuition and the Akaike information criterion. Eighty percent of the sample was randomly selected for model development and 20% for model validation. Multiple logistic regression analysis was performed with Bayesian model averaging (BMA) to model the odds of 90-day readmission. Goodness of fit was assessed via the C-statistic, that is, the area under the receiver operating characteristic curve (AUC), using the training data set. Discrimination (predictive performance) was assessed using the C-statistic, as applied to the 20% validation data set. RESULTS A total of 2803 consecutive patients were enrolled in the registry, and their data were analyzed for this study. Of this cohort, 227 (8.1%) patients were readmitted to the hospital (for any cause) within 90 days postoperatively. Variables significantly associated with an increased risk of readmission were as follows (OR [95% CI]): lumbar surgery 1.8 [1.1-2.8], government-issued insurance 2.0 [1.4-3.0], hypertension 2.1 [1.4-3.3], prior myocardial infarction 2.2 [1.2-3.8], diabetes 2.5 [1.7-3.7], and coagulation disorder 3.1 [1.6-5.8]. These variables, in addition to others determined a priori to be clinically relevant, comprised 32 inputs in the predictive model constructed using BMA. The AUC value for the training data set was 0.77 for model development and 0.76 for model validation. CONCLUSIONS Identification of high-risk patients is feasible with the novel predictive model presented herein. Appropriate allocation of resources to reduce the postoperative incidence of readmission may reduce the readmission rate and the associated health care costs.
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http://dx.doi.org/10.3171/2018.1.SPINE17505DOI Listing
September 2018

Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy.

Neurosurgery 2018 12;83(6):1153-1160

Department of Orthopedics Surgery, Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: The healthcare reimbursement models are rapidly transitioning to pay-per-performance episode of care payment models. These models, if designed well, must account for the variability in the cost of index surgeries during the global period.

Objective: To analyze the variability in 90-d cost and determine the drivers of the variability in total 90-d cost associated with single-level microdiscectomy.

Methods: A total of 203 patients undergoing primary microdiscectomy for degenerative lumbar conditions were included in the study. The total 90-d cost was derived as the sum of cost of surgery, cost associated with postdischarge utilization. A multivariable linear regression model for total 90-d cost was built.

Results: The mean total cost within 90-d after single-level primary microdiscectomy was $7962 ± $2092. In a multivariable linear regression model, obesity, history of myocardial infarction, factors that lengthen the time of surgery and hospital stay, complications and readmission within 90-d, postdischarge healthcare utilization including emergency room visits, time to opioid independence, number of days on nonopioid pain medications, diagnostic imaging, and the number of days in outpatient and inpatient rehabilitation contribute to the total 90-d cost. The model performance as measured by R2 is 0.76.

Conclusion: Utilizing prospectively collected data, we highlight major drivers of variation in cost following a single-level primary microdiscectomy. Our model explains about three-quarters of the variation in cost. The risk-adjusted cost estimates powered by models such as the one presented here can be used to formulate a sustainable total 90-d episode of care bundle payment.
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http://dx.doi.org/10.1093/neuros/nyy209DOI Listing
December 2018

Comparison of Outcomes Following Anterior vs Posterior Fusion Surgery for Patients With Degenerative Cervical Myelopathy: An Analysis From Quality Outcomes Database.

Neurosurgery 2019 04;84(4):919-926

Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.

Background: The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial.

Objective: To compare the outcomes following the 2 approaches using multicenter prospectively collected data.

Methods: Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy [ACDF] or corpectomy [ACCF] with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes.

Results: Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups.

Conclusion: Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.
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http://dx.doi.org/10.1093/neuros/nyy144DOI Listing
April 2019

Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease.

Neurosurgery 2018 11;83(5):898-904

Department of Orthopedics Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

Objective: To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

Methods: Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

Results: The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

Conclusion: There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.
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http://dx.doi.org/10.1093/neuros/nyy140DOI Listing
November 2018

Spine Surgery in the Ambulatory Surgery Center Setting: Value-Based Advancement or Safety Liability?

Neurosurgery 2018 08;83(2):159-165

Depart-ment of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina.

Here, we systematically review clinical studies that report morbidity and outcomes data for cervical and lumbar surgeries performed in ambulatory surgery centers (ASCs). We focus on anterior cervical discectomy and fusion (ACDF), posterior cervical foraminotomy, cervical arthroplasty, lumbar microdiscectomy, lumbar laminectomy, and minimally invasive transforaminal interbody fusion (TLIF) and lateral lumbar interbody fusion, as these are prevalent and surgical spine procedures that are becoming more commonly performed in ASC settings.A systematic search of PubMed was conducted, using combinations of the following phrases: "outpatient," "ambulatory," or "ASC" with "anterior cervical discectomy fusion," "ACDF," "cervical arthroplasty," "lumbar," "microdiscectomy," "laminectomy," "transforaminal lumbar interbody fusion," "spine surgery," or "TLIF."In reviewing the available literature to date, there is ample level 3 (retrospective comparisons) and level 4 (case series) evidence to support both the safety and effectiveness of outpatient cervical and lumbar surgery. While no level 1 or 2 (randomized clinical trials) evidence currently exists, the plethora of real-world clinical data creates a formidable argument for serious investments in ASCs for multiple spine procedures.
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http://dx.doi.org/10.1093/neuros/nyy057DOI Listing
August 2018

Impact of Psychiatric Comorbidities on Short-Term Outcomes Following Intervention for Lumbar Degenerative Disc Disease.

Spine (Phila Pa 1976) 2018 Oct;43(19):1363-1371

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA.

Study Design: Retrospective, observational cohort study.

Objective: To investigate the impact of psychiatric diseases on short-term outcomes in patients undergoing fusion surgery for lumbar degenerative disc disease (LDDD).

Summary Of Background Data: Limited literature exists on the prevalence and impact of psychiatric comorbidities on outcomes in patients undergoing surgery for LDDD.

Methods: Adult patients (>18 yr) registered in the Nationwide Inpatient Sample database (2002-2011) and undergoing an elective spine fusion for LDDD that met inclusion criteria formed the study population. Defined primary outcome measures were discharge disposition, length of stay, hospitalization cost, and short-term postsurgical complications (neurological, respiratory, cardiac, gastrointestinal, wound complication and infections, venous thromboembolism, and acute renal failure). Multivariable regression techniques were used to explore the association of psychiatric comorbidities on short-term outcomes by adjusting for patient demographics, clinical, and hospital characteristics.

Results: Of the 126,044 adult patients undergoing fusion surgery for LDDD (mean age: 54.91 yr, 58% female) approximately 18% had a psychiatric disease. Multivariable regression analysis revealed patients with psychiatric disease undergoing fusion surgery have higher likelihood for unfavorable discharge (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.35-1.47; P < 0.001), length of stay (OR 1.03; 95% CI 1.02-1.04; P < 0001), postsurgery neurologic complications (OR 1.25; 95% CI 1.13-1.37; P < 0.001), venous thromboembolic events (OR 1.38 95% CI 1.26-1.52; P < 0.001), and acute renal failure (OR 1.17; 95% CI 1.01-1.37; P = 0.040). Patients with psychiatric disease were also associated to have higher hospitalization cost (6.3% higher; 95% CI: 5.6%-7.1%; P < 0.001) compared to those without it.

Conclusion: Our study quantifies the estimates for presence of concomitant psychiatric comorbid conditions on short outcomes in patients undergoing fusions for LDDD. The data provide supporting evidence for adequate preoperative planning and postsurgical care including consultation for mental health for favorable outcomes.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002616DOI Listing
October 2018

Association of Annular Defect Width After Lumbar Discectomy With Risk of Symptom Recurrence and Reoperation: Systematic Review and Meta-analysis of Comparative Studies.

Spine (Phila Pa 1976) 2018 03;43(5):E308-E315

Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Study Design: Systematic review and meta-analysis of comparative studies.

Objective: To characterize the association of annular defect width after lumbar discectomy with the risk of symptom recurrence and reoperation.

Summary Of Background Data: Large annular defect width after lumbar discectomy has been reported to increase risk of symptom recurrence. However, this association has not been evaluated in a systematic manner.

Methods: A systematic literature search of MEDLINE and EMBASE was performed to identify comparative studies of large versus small annular defects following lumbar discectomy that reported symptom recurrence or reoperation rates. Main outcomes were reported with pooled odds ratios (OR) and 95% confidence intervals (CIs). Sensitivity analyses were performed to assess the robustness of the meta-analysis findings.

Results: After screening 696 records, we included data from 7 comparative studies involving 1653 lumbar discectomy patients, of whom 499 (30%) had large annular defects and 1154 (70%) had small annular defects. Methodological quality of studies was good overall. The median follow-up period was 2.9 years. The risk of symptom recurrence (OR = 2.5, 95% CI = 1.3-4.5, P = 0.004) and reoperation (OR = 2.3, 95% CI = 1.5-3.7, P < 0.001) was higher in patients with large versus small annular defects. Publication bias was not evident. The associations between annular defect width and risk of symptom recurrence and reoperation remained statistically significant in all sensitivity analyses.

Conclusion: Annular defect width after lumbar discectomy is an under-reported modifier of patient outcome. Risk for symptom recurrence and reoperation is higher in patients with large versus small annular defects following lumbar discectomy.

Level Of Evidence: 2.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815639PMC
March 2018

Effect of patients' functional status on satisfaction with outcomes 12 months after elective spine surgery for lumbar degenerative disease.

Spine J 2017 12 29;17(12):1783-1793. Epub 2017 Sep 29.

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neurological Institute, Carolinas Healthcare System, Charlotte, NC, USA. Electronic address:

Background: Comprehensive assessment of quality of care includes patient-reported outcomes, safety of care delivered, and patient satisfaction. The impact of the patient-reported Oswestry Disability Index (ODI) scores at baseline and 12 months on satisfaction with outcomes following spine surgery is not well documented.

Purpose: This study aimed to determine the impact of patient disability (ODI) scores at baseline and 12 months on satisfaction with outcomes following surgery.

Study Design: Analysis of prospectively collected longitudinal web-based multicenter data.

Patient Sample: Patients undergoing elective surgery for degenerative lumbar disease were entered into a prospective multicenter registry.

Outcome Measures: Primary outcome measures were ODI, North American Spine Society satisfaction (NASS) questionnaire.

Methods: Baseline and 12-month ODI scores were recorded. Satisfaction at 12 months after surgery was measured using NASS questionnaire. Multivariable proportional odds logistic regression analysis was conducted to determine the impact of baseline and 12-month ODI on satisfaction with outcomes.

Results: Of the total 5,443 patients, 64% (n=3,460) were satisfied at a level where surgery met their expectations (NASS level 1) at 12 months after surgery. After adjusting for all baseline and surgery-specific variables, the 12-month ODI score had the highest impact (Wald χ=1,555, 86% of the total χ) on achieving satisfaction with outcomes compared with baseline ODI scores (Wald χ=93, 5% of the total χ). The level of satisfaction decreases with increasing 12-month ODI score. Greater change in ODI is required to achieve a better satisfaction level when the patient starts with a higher baseline ODI score.

Conclusion: Absolute 12-month ODI following surgery had a significant association on satisfaction with outcomes 12 months after surgery. Patients with higher baseline ODI required a larger change in ODI score to achieve satisfaction. No single measure can be used as a sole yardstick to measure quality of care after spine surgery. Satisfaction may be used in conjunction with baseline and 12-month ODI scores to provide an assessment of the quality of spine surgery provided in a patient centric fashion.
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http://dx.doi.org/10.1016/j.spinee.2017.05.027DOI Listing
December 2017

Effect of Complications within 90 Days on Cost Per Quality-Adjusted Life Year Gained Following Elective Surgery for Degenerative Lumbar Spine Disease.

Neurosurgery 2017 09;64(CN_suppl_1):157-164

Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

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http://dx.doi.org/10.1093/neuros/nyx356DOI Listing
September 2017

Surgeon-Level Variability in Outcomes, Cost, and Comorbidity Adjusted-Cost for Elective Lumbar Decompression and Fusion.

Neurosurgery 2018 04;82(4):506-515

Department of Orthopaedic Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: The costs and outcomes following degenerative spine surgery may vary from surgeon to surgeon. Patient factors such as comorbidities may increase the health care cost. These variations are not well studied.

Objective: To understand the variation in outcomes, costs, and comorbidity-adjusted cost for surgeons performing lumbar laminectomy and fusions surgery.

Methods: A total of 752 patients undergoing laminectomy and fusion, performed by 7 surgeons, were analyzed. Patient-reported outcomes and 90-d cost were analyzed. Multivariate regression model was built for high-cost surgery. A separate linear regression model was built to derive comorbidity-adjusted 90-d costs.

Results: No significant differences in improvement were found across all the patient-reported outcomes, complications, and readmission among the surgeons. In multivariable model, surgeons #4 (P < .0001) and #6 (P = .002) had higher odds of performing high-cost fusion surgery. The comorbidity-adjusted costs were higher than the actual 90-d costs for surgeons #1 (P = .08), #3 (P = .002), #5 (P < .0001), and #7 (P < .0001), whereas they were lower than the actual costs for surgeons #2 (P = .128), #4 (P < .0001), and #6 (P = .44).

Conclusion: Our study provides valuable insight into variations in 90-d costs among the surgeons performing elective lumbar laminectomy and fusion at a single institution. Specific surgeons were found to have greater odds of performing high-cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patients' preoperative comorbidities must be accounted for when crafting value-based payment models. Furthermore, designing intervention targeting "modifiable" factors tied to the way the surgeons practice may increase the overall value of spine care.
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http://dx.doi.org/10.1093/neuros/nyx243DOI Listing
April 2018

Impact of Discharge Disposition on 30-Day Readmissions Following Elective Spine Surgery.

Neurosurgery 2017 Nov;81(5):772-778

Department of Orthopedics and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Readmissions are a significant economic burden on the health care system and increasingly being utilized as a metric of quality. Patients discharged to home vs an inpatient facility have different characteristics, which might influence the readmissions following spine surgery.

Objective: To determine the effect of discharge disposition on readmission rates and causes of readmission after spine surgery.

Methods: Patients enrolled in a prospective registry and undergoing elective spine surgery were analyzed. Readmissions (30 d), demographic, clinical variables, and baseline patient-reported outcomes were recorded. Patients were dichotomized as discharged home vs inpatient facility.

Results: Of total 1631 patients, 1444 (89%) patients were discharged home and 187 (11%) discharged to an inpatient facility. Sixty-five (4%) patients were readmitted at 30 d. There was no significant difference in readmissions between patients discharged to a facility 10 (5%) vs home 55 (4%; P = .210). In a multivariable analysis, adjusting for all the comorbidities, the discharge destination was not associated with readmission within 30 d. The medical complications (80%) were the most common cause of readmission in those discharged to a facility. Patients discharged home had significantly higher readmissions related to surgical wound issues (67%; P = .034).

Conclusion: Despite the older age and higher comorbidities in patients discharged to an inpatient facility, the proportion of readmissions was comparable to those discharged home. Patients discharged home had a higher proportion of readmissions related to surgical wound complications and those discharged to facility had higher readmissions associated with medical complications. Understanding causes of readmission based on discharge destination may allow targeted intervention to reduce the readmission rates following spine surgery.
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http://dx.doi.org/10.1093/neuros/nyx114DOI Listing
November 2017

Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors.

Neurosurgery 2017 Oct;81(4):613-619

Department of Orthopedics Surgery and Department of Neurological surgery, Spinal Column Surgical Quality and Out-comes Research Laboratory, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported.

Objective: To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors.

Methods: Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost).

Results: A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314.

Conclusion: Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.
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http://dx.doi.org/10.1093/neuros/nyw126DOI Listing
October 2017

An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making.

J Neurosurg Spine 2017 Oct 12;27(4):357-369. Epub 2017 May 12.

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina.

OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.
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http://dx.doi.org/10.3171/2016.11.SPINE16526DOI Listing
October 2017

An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease.

J Neurosurg Spine 2017 Oct 12;27(4):370-381. Epub 2017 May 12.

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina.

OBJECTIVE Current costs associated with spine care are unsustainable. Productivity loss and time away from work for patients who were once gainfully employed contributes greatly to the financial burden experienced by individuals and, more broadly, society. Therefore, it is vital to identify the factors associated with return to work (RTW) after lumbar spine surgery. In this analysis, the authors used data from a national prospective outcomes registry to create a predictive model of patients' ability to RTW after undergoing lumbar spine surgery for degenerative spine disease. METHODS Data from 4694 patients who underwent elective spine surgery for degenerative lumbar disease, who had been employed preoperatively, and who had completed a 3-month follow-up evaluation, were entered into a prospective, multicenter registry. Patient-reported outcomes-Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (BP) and leg pain (LP), and EQ-5D scores-were recorded at baseline and at 3 months postoperatively. The time to RTW was defined as the period between operation and date of returning to work. A multivariable Cox proportional hazards regression model, including an array of preoperative factors, was fitted for RTW. The model performance was measured using the concordance index (c-index). RESULTS Eighty-two percent of patients (n = 3855) returned to work within 3 months postoperatively. The risk-adjusted predictors of a lower likelihood of RTW were being preoperatively employed but not working at the time of presentation, manual labor as an occupation, worker's compensation, liability insurance for disability, higher preoperative ODI score, higher preoperative NRS-BP score, and demographic factors such as female sex, African American race, history of diabetes, and higher American Society of Anesthesiologists score. The likelihood of a RTW within 3 months was higher in patients with higher education level than in those with less than high school-level education. The c-index of the model's performance was 0.71. CONCLUSIONS This study presents a novel predictive model for the probability of returning to work after lumbar spine surgery. Spine care providers can use this model to educate patients and encourage them in shared decision-making regarding the RTW outcome. This evidence-based decision support will result in better communication between patients and clinicians and improve postoperative recovery expectations, which will ultimately increase the likelihood of a positive RTW trajectory.
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http://dx.doi.org/10.3171/2016.8.SPINE16527DOI Listing
October 2017

Predictors of extended length of stay, discharge to inpatient rehab, and hospital readmission following elective lumbar spine surgery: introduction of the Carolina-Semmes Grading Scale.

J Neurosurg Spine 2017 Oct 12;27(4):382-390. Epub 2017 May 12.

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina.

OBJECTIVE Extended hospital length of stay (LOS), unplanned hospital readmission, and need for inpatient rehabilitation after elective spine surgery contribute significantly to the variation in surgical health care costs. As novel payment models shift the risk of cost overruns from payers to providers, understanding patient-level risk of LOS, readmission, and inpatient rehabilitation is critical. The authors set out to develop a grading scale that effectively stratifies risk of these costly events after elective surgery for degenerative lumbar pathologies. METHODS The Quality and Outcomes Database (QOD) registry prospectively enrolls patients undergoing surgery for degenerative lumbar spine disease. This registry was queried for patients who had undergone elective 1- to 3-level lumbar surgery for degenerative spine pathology. The association between preoperative patient variables and extended postoperative hospital LOS (LOS ≥ 7 days), discharge status (inpatient facility vs home), and 90-day hospital readmission was assessed using stepwise multivariate logistic regression. The Carolina-Semmes grading scale was constructed using the independent predictors for LOS (0-12 points), discharge to inpatient facility (0-18 points), and 90-day readmission (0-6 points), and its performance was assessed using the QOD data set. The performance of the grading scale was then confirmed separately after using it in 2 separate neurosurgery practice sites (Carolina Neurosurgery & Spine Associates [CNSA] and Semmes Murphey Clinic). RESULTS A total of 6921 patients were analyzed. Overall, 290 (4.2%) patients required extended LOS, 654 (9.4%) required inpatient facility care/rehabilitation on hospital discharge, and 474 (6.8%) were readmitted to the hospital within 90 days postdischarge. Variables that remained as independently associated with these unplanned events in multivariate analysis included age ≥ 70 years, American Society of Anesthesiologists Physical Classification System class > III, Oswestry Disability Index score ≥ 70, diabetes, Medicare/Medicaid, nonindependent ambulation, and fusion. Increasing point totals in the Carolina-Semmes scale effectively stratified the incidence of extended LOS, discharge to facility, and readmission in a stepwise fashion in both the aggregate QOD data set and when subsequently applied to the CNSA/Semmes Murphey practice groups. CONCLUSIONS The authors introduce the Carolina-Semmes grading scale that effectively stratifies the risk of prolonged hospital stay, need for postdischarge inpatient facility care, and 90-day hospital readmission for patients undergoing first-time elective 1- to 3-level degenerative lumbar spine surgery. This grading scale may be helpful in identifying patients who may require additional resource utilization within a global period after surgery.
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http://dx.doi.org/10.3171/2016.12.SPINE16928DOI Listing
October 2017

Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism?

Neurosurgery 2017 May;80(5):746-753

Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nas-hville, Tennessee.

Background: Surgical site infection (SSI) following spine surgery is a morbid and expensive complication. The use of intrawound vancomycin is emerging as a solution to reduce SSI. The development of vancomycin-resistant pathogens is an understandable concern.

Objective: To determine the occurrence of vancomycin-resistant SSI in patients with and without use of intrawound vancomycin.

Methods: Patients undergoing elective spine surgery were dichotomized based on whether intrawound vancomycin was applied. Outcome was occurrence of SSI requiring return to the operating room within postoperative 90 days. The intrawound culture and vancomycin minimal inhibitory concentrations (MIC) were reviewed. Analyses were conducted to compare the pathogen profile and MIC for vancomycin in patients who received vancomycin and those who did not.

Results: Of the total 2802 patients, 43% (n = 1215) had intrawound vancomycin application during the index surgery. The use of vancomycin was associated with significantly lower deep SSI rates (1.6% [n = 20] vs 2.5% [n = 40], P = .02). The occurrence of Staphylococcus aureus SSI was significantly lower in the patients who had application of intrawound vancomycin (32% vs 65%, P = .003). None of the patients who had application of intrawound vancomycin powder, and subsequently developed an S aureus SSI, demonstrated pathogens with resistance to vancomycin. All patients had MIC < 2 μg/mL, the vancomycin susceptibility threshold. The occurrence of gram-negative SSI (28% vs 7%) and culture negative fluid collection (16% vs 5%) was higher in the vancomycin cohort.

Conclusions: The use of intrawound vancomycin during the index spine surgery was protective against SSI following spine surgery. The application of intrawound vancomycin during index surgery does not appear to create vancomycin-resistant organisms in the event of an SSI.
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May 2017

Bending the Cost Curve-Establishing Value in Spine Surgery.

Neurosurgery 2017 Mar;80(3S):S61-S69

Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina.

Background: As publically promoted by all stakeholders in health care reform, prospective outcomes registry platforms lie at the center of all current evidence-driven value-based models.

Objective: To demonstrate the variability in outcomes and cost at population level and individual patient level for patients undergoing spine surgery for degenerative diseases.

Methods: Retrospective analysis of prospective longitudinal spine registry data was conducted. Baseline and postoperative 1-year patient-reported outcomes were recorded. Previously published minimal clinically important difference for Oswestry Disability Index (14.9) was used. Back-related resource utilization and quality-adjusted life years (QALYs) were assessed. Variations in outcomes and cost were analyzed at population level and at the individual patient level.

Results: A total of 1454 patients were analyzed. There was significant improvement in patient-reported outcomes at postoperative 1 year ( P < .0001). For patients demonstrating health benefit at population level, 12.5%, n = 182 of patients experienced no gain from surgery and 38%, n = 554 failed to achieve minimal clinically important difference. Mean 1-year QALY-gained was 0.29; 18% of patients failed to report gain in QALY. For patients with 2-year follow-up, surgery resulted in 0.62 QALY-gained at average direct cost of $28 953. A wide variation in both QALY-gained and cost was observed.

Conclusion: Spine treatments that on average are cost-effective may have wide variability in value at the individual patient level. The variability demonstrated here represents an opportunity, through registries, to identify specific care that may be less effective, and refine patient-specific care delivery and indications to drive overall group-level treatment value. Understanding value of spine care at an individualized as well as population level will allow clinicians, and eventually payers, to better target resources for improving care for nonresponders, ultimately driving up the average health for the whole population.
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http://dx.doi.org/10.1093/neuros/nyw081DOI Listing
March 2017

The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies.

Eur Spine J 2017 11 10;26(11):2719-2728. Epub 2017 Mar 10.

Department of Neurological Surgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA.

Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) play an important role in postoperative pain management. However, their use in the setting of spine fusion surgery setting has long been a topic of controversy. In this review we examined relevant research, including in vivo, animal, and clinical human studies, with the aim of understanding the effect of NSAIDs on spinal fusion.

Study Design/setting: Systematic review of study designs of all types from randomized controlled trials and meta-analyses to single-institution retrospective reviews.

Methods: A search of PubMed and Embase was conducted using the keywords: "spine," "spinal fracture," NSAIDs, anti-inflammatory non-steroidal agents, bone, bone healing, fracture, fracture healing, yielding a total of 110 studies. Other 28 studies were identified by cross-referencing, resulting in total 138 studies.

Results: There is no level I evidence from human studies regarding the use of NSAIDs on spinal fusion rates. The overall tone of the spine literature in the early 2000s was that NSAIDs increased the rate of non-union; however, nearly all human studies published after 2005 suggest that short-term (<2 weeks) postoperative use have no such effect. The dose dependency that is seen with a 2-week postoperative course is not present when NSAIDs are only used for 48 h after surgery.

Conclusions: NSAID appear to have dose-dependent and duration-dependent effects on fusion rates. The short-term use of low-dose NSAIDs around the time of spinal fusion surgery is reasonable. Spine surgeons can consider the incorporation of NSAIDs into pain control regimens for spinal fusion patients with the goal of improving pain control and reducing the costs and complications associated with opioids.
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http://dx.doi.org/10.1007/s00586-017-5021-yDOI Listing
November 2017
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